Dr Imran Sajid

EASL Guideline-Based Chronic Hepatitis B Treatment Algorithm

HBV DNA ≥2,000 IU/mL is a major treatment threshold in non-cirrhotic patients.

EASL Recommends treatment when HBV DNA ≥2,000 IU/mL plus one or more of the following:

--Elevated ALT
--Significant fibrosis
--Risk factors for HCC
--Extrahepatic manifestations
--Immunosuppression
--Risk of HBV transmission

EASL Emphasizes treatment in all patients with cirrhosis/advanced fibrosis and detectable HBV DNA.

Vitamin B6 (Pyridoxine)

The classic vitamin that can cause peripheral neuropathy both when deficient and when taken in excess is Vitamin B6 (pyridoxine).

hypernatremia, an easy approach is:
Check urine osmolality first.

ADHD = Attention-Deficit/Hyperactivity Disorder

Definition:
ADHD is a multifactorial neurodevelopmental disorder caused by an interaction of genetic, environmental, and neurobiological factors, not a single cause.

Genetic factors

High heritability: ~70–80%
Multiple genes contribute small effects
Important genes linked to dopamine signaling:
* DRD4
* DRD5
* DAT1

Environmental factors
Prenatal and early-life influences may interact with genetic susceptibility:

Maternal stress during pregnancy
Toxin exposure
Prematurity
Early-life adversity

🧠 Neurobiological mechanisms
Affected brain regions:

Prefrontal cortex
Basal ganglia
Fronto-striatal circuits
Attention networks

Results in impaired:

Attention
Executive function
Impulse control
Reward processing

Neurotransmitters involved

↓ Dopamine function
↓ Noradrenaline function

Hypercalcemia + Acid–Base Disorders: Causes

Hypercalcemia + metabolic alkalosis + renal dysfunction → think Milk-alkali syndrome first.

Hypercalcemia + metabolic acidosis → think Primary hyperparathyroidism first (PTH causes bicarbonate wasting → mild hyperchloremic metabolic acidosis).

Luftsichel sign = Air crescent beside the aortic arch → Think Left Upper Lobe Collapse first.

Definition:
The Luftsichel sign (“luft” = air, “sichel” = sickle in German) is a classic chest X-ray sign of left upper lobe (L*L) collapse (atelectasis).

Mechanism:
When the left upper lobe collapses, it shifts anteriorly and superiorly. The superior segment of the left lower lobe expands (hyperinflates) and moves into the space between the collapsed upper lobe and the aortic arch, creating a crescent/sickle-shaped air lucency adjacent to the aortic arch.

Chest X-ray Findings:
• Crescent-shaped hyperlucent area along the left side of the aortic arch
• Evidence of left upper lobe volume loss
• Elevated left hilum
• Leftward mediastinal shift (may occur)
• Veil-like opacity of the left upper lung field

Common Causes of Left Upper Lobe Collapse:
• Bronchogenic carcinoma
• Endobronchial obstruction (tumor, mucus plug)
• Foreign body aspiration
• Enlarged lymph nodes causing compression
• Postoperative atelectasis

NICE referral pathway for Suspected Heart Failure Evaluation

Previous MI → Echocardiogram + specialist review within 2 weeks

If no previous MI:

NT-proBNP >2000 ng/L (236 pmol/L) within 2 weeks
NT-proBNP 400–2000 ng/L → within 6 weeks
NT-proBNP

Hypercoagulable States

Inherited thrombophilias:

Factor V Leiden mutation
Prothrombin gene mutation
Protein C deficiency
Protein S deficiency
Antithrombin III deficiency

Acquired conditions:

Antiphospholipid Syndrome
Malignancy
Pregnancy and postpartum period
Oral contraceptive use

COPD Treatment (latest GOLD practical summary)

• All patients:
– Smoking cessation
– Vaccinations (influenza, pneumococcal, COVID)
– Pulmonary rehabilitation if symptomatic
– Rescue inhaler: SABA (e.g., albuterol/salbutamol) PRN

Renal vein thrombosis (RVT)

Classic clinical features: flank pain, hematuria, enlarged kidney, proteinuria, and sometimes acute kidney injury.

In nephrotic syndrome, RVT may be asymptomatic and discovered incidentally.

Common causes and risk factors include:

Mnemonic: “NEPHROTIC”

Nephrotic syndrome
Extrinsic compression
Pregnancy/OCPs
Hypercoagulable states
Renal cell carcinoma
Operations/trauma
Transplant kidney
Inflammatory disorders
Childhood dehydration